title: 'My dreams are shuttered down and it hurts lots'-a qualitative study of palliative care needs and their management by HIV outpatient services in Kenya and Uganda.
abstract: BACKGROUND
  Despite the huge burden of HIV in sub-Saharan Africa, there is little evidence of the multidimensional needs of patients with HIV infection to inform the person-centred care across physical, psychological, social and spiritual domains stipulated in policy guidance. We aimed to describe the problems experienced by people with HIV in Kenya and Uganda and the management of these problems by HIV outpatient services.
  
  
  METHODS
  Local researchers conducted in depth qualitative interviews with HIV patients, caregivers and service staff at 12 HIV outpatient facilities (6 in Kenya, 6 in Uganda). Interview data were analysed thematically.
  
  
  RESULTS
  189 people were interviewed (83 patients, 47 caregivers, 59 staff). The impact of pain and symptoms and their causes (HIV, comorbidities, treatment side-effects) were described. Staff reported that effective pain relief was not always available, particularly in Kenya. Psychosocial distress (isolation, loneliness, worry) was exacerbated by stigma and poverty, and detrimentally affected adherence. Illness led to despair and hopelessness. Provision of counselling was reported, but spiritual support appeared to be less common. Neither pain nor psychosocial problems were routinely reported to service staff. Collaboration with local hospices and income-generation activities for patients were highlighted as useful.
  
  
  CONCLUSIONS
  The findings demonstrate the multiple and interrelated problems associated with living with HIV and how psychosocial and spiritual distress can contribute to 'total pain' in this population. In line with the palliative care approach, HIV care requires holistic care and assessment that take into account psychological, socioeconomic and spiritual distress alongside improved access to pain-relieving drugs, including opioids.
authors.affiliation: King's College London, Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, Bessemer Road, London SE5 9PJ, UK. lucy.selman@kcl.ac.uk.
authors.forename: Lucy
authors.initials: L
authors.lastname: Selman
authors.forename: Victoria
authors.initials: V
authors.lastname: Simms
authors.forename: Suzanne
authors.initials: S
authors.lastname: Penfold
authors.forename: Richard A
authors.initials: RA
authors.lastname: Powell
authors.forename: Faith
authors.initials: F
authors.lastname: Mwangi-Powell
authors.forename: Julia
authors.initials: J
authors.lastname: Downing
authors.forename: Nancy
authors.initials: N
authors.lastname: Gikaara
authors.forename: Grace
authors.initials: G
authors.lastname: Munene
authors.forename: Irene J
authors.initials: IJ
authors.lastname: Higginson
authors.forename: Richard
authors.initials: R
authors.lastname: Harding